Jeffrey G. Kaplan

Anderson Cancer Center in Houston; Jeffrey G. Kaplan, M.D., network medical director of Wellcare of New York, Inc.

Another MCO that offers access to multidisciplinary pain management is WellCare, in Kingston, N.Y. Referrals for pain are generally at the discretion of the primary care physician, says Jeffrey Kaplan, MD, WellCare's network medical director.The plan does not specify the number of visits or treatment that must be tried first.Some pain patients may be referred to orthopedic specialists and other alternative medical services or physical therapy outside of pain centers, Kaplan says.WellCare covers a maximum of 30 outpatient physical therapy visits, but patients must exhibit improvement after three visits.Improvement in orthopedic therapy is assessed by examining whether health care utilization decreases.Inpatient physical therapy is not limited, but clinical benefit must be demonstrated.

WellCare case managers examine records of patients with pain or other conditions who make a higher than average number of office visits, who receive more than a minimal number of prescriptions for opioids or especially expensive pain medications, or who have treatment-induced side effects.The HMO may make a referral to a pain clinic in cases of over utilization and may pay a flat fee for each case, Kaplan says.